Journal of Orthopedic Practice Open Access Research Article
Volume 1 – Issue 1
Surgical management of continuous and mixed type of OPLL in cervical spine: Experience in tertiary level hospital. Md. Kamrul Ahsan1,*, Shahidul Islam Khan2, Sachindra Raj Joshi3, Ravish Pandey3, Abu Rifat Md Mofazzal3, Abdullah AL Mahaj Chowdhury3, Nazmin Ahmed4 1
Professor of Spinal Surgery, Department of Orthopaedic Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Shahbag,
Dhaka 2
Medical Officer, MS (Orthopaedic Surgery), Dept of Orthopaedic Surgery, BSMMU, Dhaka
3
Resident, Department of Orthopaedic Surgery, BSMMU
4
Registrar Department of Neurosurgery, BIRDEM, Dhaka, Bangladesh
*
Corresponding author: Kamrul Ahsan, Professor of Spinal Surgery, Department of Orthopaedic Surgery, Bangabandhu Sheikh Mujib
Medical University (BSMMU), Shahbag, Dhaka Received date: 19 November, 2021 |
Accepted date: 29 November, 2021 |
Published date: 1 December, 2021
Citation: Ahsan K, Khan SI, Joshi SR, Pandey R, Mofazzal AR, et al. (2021). Surgical management of continuous and mixed type of OPLL in cervical spine: Experience in tertiary level hospital. J Orthop Pract 1(1). doi https://doi.org/10.54289/JOP2100104 Copyright: © 2021 Ahsan K, Khan SI, Joshi SR, Pandey R, Mofazzal AR, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract Background: Ossification of the posterior longitudinal ligament (OPLL) is a chronically progressive disease of ectopic enchondral and membranous ossification of posterior longitudinal ligament (PLL). Controversy still persists over the superiority of various surgical approaches for cervical OPLL management. Purpose: To see the efficacy of expansive laminoplasty for the management of continuous and mixed type of cervical OPLL retrospectively. Methods: Records of 20 male and 8 female aged 36-72 years (mean, 56.64 years), who underwent surgical treatment posteriorly for continuous and mixed type OPLL by laminoplasty were obtained from the year 2004 - 2020. Clinical features along with imaging studies, which included X -ray/CT /MRI, were done for the diagnosis of OPLL. Multiple variables were studied, including demographics, surgical parameters, complications and functional outcomes. Results: They were followed on an average of 59.86 ± 20.95 months (range, 24 -108 months). The average operative duration was 95 ± 15.52 min (range: 70 - 140), and the intraoperative blood loss was 199.29 ± 33.55 ml. The cervical curvature index reduced to 8.81 ± 1.96 from 11.00 ± 2.49 and the VAS score decreased from 4.25 ± 0.75 to 2.43 ± 1.40. mJOA score improved from 8.64 ± 1.03 to 13.96 ± 1.26 on the last follow-up after surgery (p < 0.01), with average recovery rate of 65.5 %. Conclusions: The management for cervical myelopathy with multilevel stenosis due to continuous and mixed type of OPLL by Laminoplasty is safe and effective. Keywords: Ossification of the posterior longitudinal ligament; laminoplasty; continuous and mixed type of OPLL. Abbreviations: OPLL: Ossification of the posterior longitudinal ligament, PLL: posterior longitudinal ligament, LP: Cervical laminoplasty, LT: Laminectomy, LF: Ligamentum flavum, VAS: Visual Analog score, mJOA: Modified Japanese Orthopaedic Association score
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Journal of Orthopedic Practice
Introduction OPLL is a chronically progressive disease of ectopic enchondral and membranous ossification of posterior longitudinal ligament (PLL), of unknown etiology [1]. Once
structures and myelopathic progression is less, patient satisfaction is more along with lower rate of complications [10,11]. The main aim of this study was to evaluate the clinical outcomes of 28 patients with continuous and mixed
also called ‘Japanese disease’, it’s one of the key reasons of
type of cervical OPLL following expansive laminoplasty.
cervical myelopathy and /or radiculopathy. It was first
Methods:
described in 1960 by Tsukimato a Japanese scholar, where
From January 2004 to January 2020, total 38 OPLL patients
hypervascular fibrosis of PLL resulted in focal area of
underwent surgery in our tertiary level hospital which
calcifications, periosteal cartilaginous proliferations and
included 8 segmental, 2 circumscribed, 16 continuous and 12
ossifications [2]. It progresses, annually at the rate of 0.67mm
mixed type of OPLL. Records of 20 men 8 women aged 36-
in the antero-posterior and 4.1mm longitudinal directions,
72 years (mean, 56.64 ± 7.76 years), who underwent surgical
and also frequently extends into dura [3]. The reported
treatment posteriorly for continuous and mixed type OPLL by
prevalence of OPLL in the Japanese is 2 - 3.5%, China 0.2%
open door laminoplasty at C3-5 level (n = 10), C3-6 (n = 12)
- 1.8% and Korea 0.95%, whereas in Europeans or North
and C4-6 (n = 6) were retrospectively reviewed. Other
Americans it is less than 1% [4,5,6]. Although poorly
conditions associated with OPLL were diabetes mellitus (n =
understood, there is general agreement that pathogenesis of
16), diffuse idiopathic skeletal hyperostosis (n = 4),
OPLL is multifactorial, representing a complex interaction of
ankylosing spondylitis (n = 1), ossification of ligamentum
underlying genetic and environmental factors [7]. Recent
flavum at D10-11, D11-12 (n = 5), obesity (n = 3) and
genetic analysis suggests the involvement of certain genes,
hypoparathyroidism (n = 2). Approval from the institutional
such BMP4, BMP9, COL6A1, COL11A2 and NPPS in the
research ethics committee was acquired and informed
origin of OPLL. The fibroblasts derived from OPLL patients
consents were obtained from all participating patients.
exhibits osteoblast – like properties and PERK (a membrane
Inclusion criteria were: (1) continuous and mixed type OPLL
protein kinase) is significantly upregulated in cells from these
(2) involvement 3 or >3 level and (3) neutral to lordotic C2-7
patients in contrast to those from non OPLL patients [6,7,8].
alignment and (4) both K-line positive or negative OPLL
There are many classifications of OPLL but widely used is
patients. Excluded were:(1) segmental and focal type of
that of, Investigation Committee on OPLL of the Japanese
OPLL (2) hill-shape ossification, (3) spinal canal stenosis >
Ministry of Health, Labour and Welfare. On the basis of
60%, (4) loss of cervical curvature and (5) instability. All
lateral imaging, they are categorized into four types:
patients had axial neck pain along with pain and muscle
Segmental, Continuous, mixed and focal [9]. Frequent
weakness in upper limb; and lower limb clinical features were
progression to myelopathy has been observed in continuous
that of upper motor neuron type (e.g., weakness,
and mixed types. Depending upon the type, the management
incoordination, clumsiness and spasticity). Diagnosis was
of cervical OPLL has been described by various surgical
made by X-ray, CT scan and MRI along with clinical features
approaches, but continues to be controversial. The
(Figure 1: A, B, C, D, F, G). X-ray cervical spine standard
classification and extent of OPLL, stenosis severity, cervical
and dynamic (flexion and extension) views were done to see
spine sagittal alignment and instability, previous surgery; and
the dense ossification along the back of the vertebral bodies
surgeons experience dictates the ideal surgical approach.
and instability especially on the lateral x-ray. CT scan of
Cervical laminoplasty (LP) and laminectomy (LT) with or
cervical spine along with screening film were done to see the
without fusion are the most commonly used procedures for
extend and type of OPLL, identified any foraminal
addressing the multilevel OPLL which can decompress the
component or the degree of stenosis, ossification of
cord either directly or indirectly but in laminoplasty, it
ligamentum flavum or any evidence of diffuse idiopathic
enlarges the spinal canal with preserving the posterior
skeletal hyperostosis (DISH) as well as the double layer sign on axial bone window which is characteristic feature of dural
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Journal of Orthopedic Practice ossification. The extent of spinal cord compression as well as
hypointense in MRI which gets enhanced after gadolinium
any pathological changes in the spinal cord was assessed by
injection. In case of pathological changes, T1 weighted shows
Magnetic resonance imaging (MRI). The OPLL appears
hypointense and T2 weighted shows hyperintense signal changes in spinal cord.
Figure 1. Preoperative plain x-ray A-P and lateral view (A, B), Sagittal, coronal and axial section CT scan (C, D, E) shows continuous type OPLL and (E, F) Sagittal and axial section T2 weighted MRI shows OPLL compressing the cord at C3 - 6 level with myelomalacic change at C 5/6 level and measurement of the C2 - C7 Cobb’s angle (H). The C2 - C7 Cobb’s angle is defined as the angle between two lines perpendicular to the lower endplates of C2 and C7.
After evaluation of medical records of all patients (28 patients), we documented all demographic parameters that included age, gender, body mass index (BMI), associated other condition, extend and type of OPLL; and surgical data which include operative duration, intraoperative blood loss, operative complications, duration of hospital stay, pre- and post-operative VAS for pain. Clinical features were evaluated pre- and postoperatively by Japanese Orthopaedic Association (JOA) score [12] (Table 1) and the recovery rate following surgery were measured by the formula as defined by Hirabayashi et al [13].
Postoperative score - preoperative score (Recovery rate (%) = ----------------------------------------------------------- ×100). Normal score (17) - preoperative score
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Journal of Orthopedic Practice Table 1: Modified Japanese Orthopedic Association score for assessment of myelopathy12 Upper extremity function
Lower extremity
Sensations
Bladder functions
function 0
• Unable to feed oneself with a
0 Unable to walk by any
spoon or by using fingers
means
Upper limp 0
• Inability to hold a pen
0
Retention
1
Severe disturbance
Apparent sensory loss Minimal sensory loss
• Total inability to carry out
1
Normal
finger hand function like buttoning shirt/house, attaching
2
watch strap 1
• Able to feed oneself with a
1
Unable to walk
spoon but not with hands
without a cane or
•Able to hold pen but unable to
other support on the
write
level.
Lower limp 0
1
Apparent sensory loss
•Inadequate evacuation the
Minimal sensory loss
bladder
Normal
• straining •dribbling of urine
2 • Clumsiness while eating food
2 Able to walk
with hands
independently on the
• Able to write, but with great
level but needs
difficulty
support on stair
•
Difficulty
Unbuttoning
in shirt/
Trunk 0
2
Mild disturbance • Hesitancy •Frequency
Apparent sensory loss Minimal sensory loss
1
Normal
buttoning/ blouse,
attaching watch strap 3 • Change in handwriting due to clumsiness •Slightly
3 Slightly clumsy in
3
Normal
walking clumsy in buttoning
shirt/blouse, attaching watch strap 4 Normal
4 Normal
Total score =17
Recovery rates was divided into 4 grade scale depending on
between the preoperative and postoperative Cobb’s angle.
improvements, i.e., excellent ≥ 90%, good 75 - 89%, fair 50 -
The change in cervical alignment of > 0° was considered as
74%, and poor ≤ 49% [14].
loss of cervical lordosis (LCL). Occupancy ratio can be
To assess the cervical alignment, Cobb's angle was calculated
calculated by dividing a (Antero-posterior diameter of OPLL)
by means of cervical spine X –ray from C2 - C7, in lateral
by b (spinal canal AP diameter) and multiplying by 100
view with neck at neutral position. It was assessed
(Figure 3: A, B). All the data were compiled and sorted
preoperatively and at 3rd, 6th month and at final follow up as
properly. The data were analyzed statistically by using SPSS
well (Figure 1: H; 2: A, B). The Cobb’s angle of <0° is
(version-25, Armonk, NY, IBM Corp). The differences
specified as cervical Kyphosis. The change of cervical
between clinical parameters were compared by Pair student’s
alignment was measured by calculating the difference
t test and p value < 0.05 was set up as level of significance.
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Journal of Orthopedic Practice
Figure 2: (A) shows preoperative cobb’s angle 120 and (B) postoperative cobb’s angle 90 after 12-months.
Figure 3: (A) shows preoperative occupancy ratio 50% and (B) postoperative occupancy ratio 38% after 12-months.
Surgical procedure
is infiltrated with a long-acting local anesthetic supplemented
After obtaining intravenous and arterial access line, all
with epinephrine which minimizes blood loss and post-
patients underwent general anaesthesia with intubation
operative pain. A midline longitudinal incision from C2 to
without cervical extension (either by glidescope or video
C7 spinous process was made. The electrocautery is then used
laryngoscope). After catheterization, the patient is positioned
to incise the ligamentum nuchae, followed by subperiosteal
prone with knees flexed so that the patient doesn’t migrate
dissection and retraction of paracervical musculature. During
caudally. The cervical spine is roughly oriented parallel to the
surgery, retractors are released periodically to allow adequate
floor by keeping the bed in reverse Trendelenburg position,
perfusion, avoiding necrosis and denervation of the muscles.
also the neck placed in a neutral or slightly flexed alignment
As semispinalis cervicis muscle has vital role in preserving
by Mayfield head holder. The shoulders are taped and the
the alignment of the cervical spine, all precaution were taken
arms are tucked at the sides of the patient with thumbs pointed
After the laminae of C3 - 6 were exposed on both sides,
towards the floor. The knees, legs, and abdomen are well
opening was made on the side where the patients had more
padded. Then painting and draping of head and neck region
symptoms. An opening is made on the lateral margin of the
are done in standard fashion. Then the midline incisional area
lamina in one side (open side); whereas in the hinge side,
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Journal of Orthopedic Practice gutter was made by removing only the dorsal cortex and
[16,17]. After the fixation of open side, if additional space
cancellous bone. The laminoplasty is then sequentially
was required; a dome-like resection was performed over the
opened by exerting a dorsolateral pressure on the lamina,
inferior and the superior one-third of the C2 & C7 lamina,
lifting it away from the canal and simultaneously, creating
respectively; without damaging the muscle-ligamentous
segmental greenstick fractures. During this maneuver, the
complex. We also performed foraminotomies where
ligamentum flavum (LF) will come under tension and needs
indicated. On the open side, we performed foraminotomies
to be released with kerrison rongeur. Once all the lamina is
after laminoplasty and plate fixation, whereas, on the hinge
elevated on the open side, fixation is applied in the form of
side foraminotomies were performed prior to laminoplasty.
titanium miniplates (double-bended 10 or 12mm plate) and
Meticulous hemostasis was obtained followed by wound
screws (7 or 8mm in length, 1.8 or 2mm diameter) (Figure 4
closure in layers with drain in situ. Post operatively, cervical
A, B, C, D; 5 a, A, B). This is classic Hirabayashi expansive
collar was used to immobilize the neck for 3 - 4 weeks.
open door laminoplasty devised by the author in 1977
Figure 4: Schematic picture demonstrated the laminoplasty technique. (A) The opening is created at the lateral mass-laminar junction by angling the burr perpendicular to the lamina and the opposite side creating a hinge, leaving the ventral cortex intact; (B) greenstick fractures are created by placing dorso-lateral tension on the spinous process or cut edge of lamina;(C) the ligamentum flavum is put under tension and cut with a Kerrison rongeur. (D) Fixation is applied.
Figure 5: (a) per-operative picture of 58-year-old male patient showing fixation by reconstruction mini plate and screws, (A, B) post operative plain x-ray A-P and lateral view, (C, D) Sagittal and axial section CT scan and (E, F) T2 weighted Sagittal and axial section MRI shows adequate enlargement of canal at 12 months follow up.
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Results:
±1.03 to 13.96 ± 1.26 on last follow-up, postoperatively (p <
They were followed on an average of 59.86 ± 20.95 months
0.01); with average recovery rate of 65.5%. (Table 2).
(range, 24 -108 months). Preoperatively, 24 patients had
Figure 5 (C, D, E, F) revealed adequate expansion of the
lordotic and 4 patients had neutral sagittal alignment. Among
canal as well as decreased occupying ratio. During operation,
28 patients, 26 patients had K line (+) and 2 patients had K
two patients (7.1%) developed dural tear and 2 patients
line (−). The mean duration of suffering was 41.64 ± 6.28
(7.1%) developed hinge breakage and were managed
months (range, 24-53 months). The average operative duration was 95 ± 15.52 min (range: 70 - 140), and the blood loss was 199.29 ± 33.55 ml (range, 140 - 260 ml). The average duration of hospital stay was 4 days (range, 3 to 7 days). The mean C2 - C7 Cobb’s angle was 9.43° ± 1.29° (range, 7° - 14°) before surgery and after surgery the mean cobb’s angle was reduced to 7.04° ± 1.32° (range, 5° - 10°, p < 0.001) with the mean of LCL of 2.39° and 10.71% of patients (3 of 28) developed kyphosis postoperatively. The occupying ratio of OPLL was 47.57 ± 5.64 % (range, 40% 60%) before surgery and after surgery occupying ratio was reduced to 35.64 ± 5.76% (range, 30% - 53%, < 0.001) (Figure 3 A, B). The VAS score decreased from 4.25 ± 0.75
accordingly. Post-operative paresthesia developed in 2 (7.1%) patients after 1 month of follow up, who recovered within 3 months. Besides, two patients (7.1%) developed transient C5 palsy, and presented with shoulder abduction weakness; they recovered within 6 months. Three patients (10.7%) reported occasional axial neck pain. Full recovery of these patients was attained after 3 months of physical therapy. There
were
hemorrhage.
no
wound
infections
or
postoperative
Late neurological deterioration of cervical
myelopathy was developed in 4 patients. Among them, two patients developed late deterioration at 3 years after operation and another 2 patients developed late deterioration at 8 and 9 years after surgery.
to 2.43 ± 1.40. mJOA score improved from preoperative 8.64 Table 2: Clinical outcome assessment by Modified Japanese Orthopedic Association score Criteria
Pre-operative
Post-operative
p value*
Upper extremity function
1.61± 0.50
2.89± 0.63
<0.001
Lower extremity function
1.32± 0.48
3.07± 0.38
<0.001
Upper limb sensation
1.00± 0.00
1.61± 0.50
<0.001
Lower Limb Sensation
1.46± 0.51
1.93± 0.26
<0.001
Trunk Sensation
1.50± 0.51
1.89± 0.32
<0.001
Bladder function
1.75± 0.52
2.57± 0.50
<0.001
Total JOA Score
8.64± 1.03
13.96± 1.26
<0.001
Recovery rate
64.65%
* Paired t test performed.
Discussion:
indirect decompression of the spinal cord, directly via an
OPLL is a multifactorial hyperostosis disorder of the PLL that
enlargement of spinal canal dimensions and removal of LF
can occur throughout the spine; however, a more commonly
and indirectly by allowing the spinal cord to drift away from
affected region is cervical vertebra, which is also one of the
the anterior compressive lesion and also, it preserved the
factors for cervical myelopathy. Hirabayashi et al. was first to
cervical motion. Patients with OPLL are either asymptomatic
introduce Laminoplasty [16]. Laminoplasty is an effective
or may present with myelopathy or myeloradiculopathy.
posterior decompression technique, which is popular among
Though there is no effective conservative treatment, patients
the spinal surgeons for the selected patients with cervical
without myelopathic symptoms or with mild symptoms
compressive myelopathy, and also have been established for
should be primarily managed nonoperatively. This also
cervical OPLL [17]. Laminoplasty results in direct and
accounts for patients with confirmed irreversible neurological
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Journal of Orthopedic Practice damage, those who can’t tolerate surgery or refusing surgery;
neck motion, but patient may develop postsurgical kyphosis
and also, in patients where neural functions weren’t restored
and postsurgical progression of OPLL and in laminectomy
after surgical decompression. Surgical intervention is
with fusion and instrumentation, this surgical procedure
suggested for those with moderate to severe myelopathy and
prevents postsurgical kyphosis and postsurgical progression
or myeloradiculopathy or in patients where conservative
of OPLL [21]. However, the range of neck motion is lost after
treatment fails. Both anterior and posterior approach can be
fusion surgery. There are two types of expansive
used as surgical intervention for cervical OPLL. As the lesion
laminoplasty – bilateral hinge type (French door/double door
in OPLL lies anteriorly, the anterior approach seems to be
laminoplasty) and the unilateral hinge type (single door/open
more feasible. However, this approach is technically
door laminoplasty). In this current study all patients
demanding and has been linked with a higher rate of serious
underwent unilateral hinge type expansive laminoplasty and
complications, such as massive intraoperative bleeding,
the average recovery rate of the mJOA score was about
neural injury, symptomatic CSF leakage, graft dislodgement,
64.65% and results after surgery according to the recovery
reconstruction failure and adjacent segment disease. On the
rate 28.6%,67.9%, and 3.6% was good, fair and poor
other hand, the posterior approach is relatively easier, where
respectively (Table 3). A meta-analysis has reported an
the entire cervical spine can be decompressed but as the
overall recovery rate of 43 to 63% following laminoplasty for
disease progresses, patients may develop late neurological
OPLL [22]. Most of the patients shows rapid improvement
deterioration. Though it is not suggested for prophylactic
within a year and continued improvement upto 10 years
surgery in asymptomatic patient because of the risk of the
following the surgery. However, progression of OPLL
surgery,
is
resulted in development of late neurological deterioration in
recommended in patients with apparent myelopathy or even
15% – 30% patients following surgery [23,24,25,26]. The
mild myelopathy with severe spinal stenosis, as irreversible
high risk of progression of OPLL was seen in patients
change in spinal cord may develop due to long-standing
younger than 50 years with the continuous or mixed types
compression of the spinal cord [18]. The optimal approach is
[27,28]. Additional reasons of late neurological deterioration
decided by patient’s general conditions, number of OPLL
were trauma and spinal cord atrophy [29]. In contrast, ossified
lesions, type and shape of OPLL, sagittal alignment, severity
LF and OPLL in the thoracic spine, has become common
of stenosis (SAC and occupying ratio), and K-line concept.
reasons of neurological deterioration [30]. Several factors that
Laminoplasty and laminectomy with/without fusion are
influence the surgical outcomes included older age (> 60
posterior decompressive techniques that can be performed
years old) [23], longer duration of preoperative symptoms (>
when the cervical lordosis is preserved and the K – line is
1 year) [31], traumatic onset [32], OPLL occupancy ratio of
positive with occupancy ratio of < 60%. In both the
>60%, kyphotic cervical alignment, myelomalacic changes in
procedures, spinal cord shifts posteriorly to achieve
MRI [33,34], and severe myelopathy; [23] which are poor
decompression [19,20]. In laminoplasty, the spinal canal is
preoperative prognostic factors.
however
early
surgical
decompression
expanded posteriorly, the laminae are preserved along with Table 3: Result after surgery according to recovery rate 13,14 Frequency
Percentage (%)
Excellent (≥ 90%)
0
0
Good (75 - 89%)
8
28.6
Fair (50 - 74%)
19
67.9
Poor (≤ 49%)
1
3.6
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Journal of Orthopedic Practice In our study 4 patients developed late deterioration of cervical
factors for C5 paralysis [46,47]. Spontaneous regression of
myelopathy (decrease JOA score > 2 points). In two of the
these complication occurs within 1-2 years with usually good
them, late deterioration occurred 3 years after operation, these
prognosis. Though expansive open door laminoplasty has
two patients had a long duration of preoperative symptoms
resulted in improved neurological outcomes, some patients
(more than 2 years), severely compromised spinal canal along
develop axial neck pain and/or stiffness around the neck and
with myelomalacic changes in MRI and subsequent follow up
shoulder [48-51]. These complaints were also observed in our
MRI showed severe spinal cord atrophy, even though there
study (10.7%) following the surgery. However, it is still not
was adequate expansion of the spinal canal. In other two
clear whether the axial pain is associated with laminoplasty
patients, the progression of ossification was attributed for late
or is merely a continuous preoperative spondylotic pain, or
neurological deterioration; and also, the both patients were
whether it represents de novo pain postoperatively. Some
diabetic & under 50 years of age. Axial neck pain and
authors have found relatively higher rates of postoperative
neurological
after
new onset neck pain,48 whereas others suggest that persistent
laminoplasty, which may be accounted due to development
pain is more common [52]. The possible factors of the axial
of sagittal malalignment following surgery [35,36,37]. LCL
pain have been described in several papers. Some researchers
following laminoplasty contributes to kyphotic angulation,
believe that the axial pains are caused due to damage to the
this does not allow the posterior shift of spinal cord, i.e.,
neck muscles and facet joints [48,49] and safeguarding of the
indirect decompression which results in residual anterior
C2 and C7 muscle attachments diminishes postoperative axial
compression. Different literature has stated that there was a 6
pain [53].
- 9% chance of development of kyphosis following
comparable, and in some studies superior, to other operations
laminoplasty
dysfunction
24
has
been
reported
which were almost consistent with our report.
In the properly selected patient, outcomes are
for OPLL.
Sakai et al. reported that following anterior decompression
Conclusions:
with fusion (ACF), there was adequate preservation of the
Expansive laminoplasty is a safe and effective non-fusion,
cervical sagittal alignment and balance; whereas following
decompressive procedure for management of cervical
laminoplasty sagittal alignment and balance was deteriorated
myelopathy with multilevel stenosis due to continuous and
[38].
mixed type of OPLL, which preserved sagittal alignment,
LCL following laminoplasty has been associated with several
motion; and minimal to no axial neck pain.
factors. The preoperative alignment of cervical lordotic
Acknowledgements: None
curvature directly affects the postoperative alignment. Suk et
Conflict of Interest: None
al.39 reported that the preoperative lordotic angle of <100 may
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